Page 1 of 2
Justin A. Welke, DDS
Patient Registration: Dental and Medical Health History
Please complete this registration form. If you have any questions, please ask.
Patient’s Name ____________________________________________ Date of Birth _____________ Today’s Date_______________
First name
Last name
Month/Day/Year
Month/Day/Year
Dental History
1.
Is this your child’s first dental visit?
Yes
No
___________________________________________
Previous Dentist’s Name
2.
Has your child ever had problems receiving dental care?
Yes No
___________________________________________
3.
Are you aware of any problems with your child’s teeth?
Yes
___________________________________________
Explain Problem(s)
No
Explain Problem(s)
4.
Who brushes the child’s teeth at home?
_______________________
______________
Who Brushes?
How Often?
5.
Is the patient receiving fluoride in any form?
Yes
No
___________________________________________
6.
Is there a history of trauma to the mouth/head/teeth?
Yes
No
___________________________________________
Type of Treatment
Explain Problem(s)
7.
Does your child suck his/her thumb/fingers/pacifier?
Yes
No
___________________________________________
8.
At what age did your child stop bottle feeding? _______________________ Breast feeding? ____________________________
Explain Problem(s)
Medical History
Physician’s/Clinic Name_________________________________________ Phone ( ______ ) _______________________________
Address ____________________________________________________________________________________________________
Street
City
State
Zip
1.
If necessary, may we consult with this physician?
Yes
No
___________________________________________
2.
Are your child’s vaccinations up to date?
Yes
No
___________________________________________
3.
Please describe any health conditions that are of present concern (medications, pending surgeries, recent injuries, issues related to healthcare)
Special Instructions
Explain Problem(s)
________________________________________________________________________________________________________
4.
Is your child being treated by a physician or alternative
medicine practitioner at this time?
Yes
No
___________________________________________
Please Describe
5.
Is your child taking any medicines, herbal medicines,
homeopathic and/or nutritional supplements at this time? Yes
No
___________________________________________
Please list Medications, Remedies and/or Supplements
_______________________________________________________________________________________
Medications, Remedies and/or Supplements
6.
Has your child ever been admitted to a hospital?
Yes
No
___________________________________________
Please Describe
7.
Has your child ever received general anesthesia/sedation? Yes
No
___________________________________________
8.
Is your child allergic to any medicines/substances/foods? Yes
No
___________________________________________
9.
Has your child ever had a blood transfusion?
No
___________________________________________
Please Describe
Please name allergy source
Yes
Please Describe
Birth History
1.
Full term
Yes
No
___________________________________________
2.
Low birth weight and/or other complications
Yes
No
___________________________________________
Please Describe
Please Describe
3.
Neo-natal Illness
Yes
No
___________________________________________
Please Describe
Rev 12/08
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Patient’s Name ____________________________________________ Date of Birth _____________ Today’s Date_______________
First name
Last name
Month/Day/Year
Month/Day/Year
Medical History (continued)
Please review the following groups of questions. Indicate if there is a current health problem, or if there was a problem in the past for your child.
Blood, Heart and Liver Organ Systems
Anemia
Yes No _________________
Hemophilia
Yes No _________________
Sickle Cell Anemia
Yes No _________________
Heart Problems
Yes
No
_________________
Hepatitis
Yes
No
_________________
HIV/AIDS
Rheumatic Fever
Yes
Yes
No
No
_________________
_________________
Leukemia
Yes
No
_________________
Other _____________________________________________
Eyes, Ears, Nose, Throat and Pulmonary System
Eye Problems
Yes No _________________
Hearing Problems
Yes No _________________
Frequent Ear Infection
Yes No _________________
Asthma
Yes No _________________
Mouth Breathing
Yes No _________________
Frequent Sore Throat
Yes No _________________
Sinus Problems
Yes No _________________
Snoring at Night
Yes No _________________
Cleft Lip/Palate
Yes No _________________
Tuberculosis
Yes No _________________
Bronchitis
Yes No _________________
Pneumonia
Yes No _________________
Other _____________________________________________
Kidney and Bladder
Renal Disease
Yes No _________________
Frequent Infections
Yes No _________________
Other _____________________________________________
Endocrine and Glands
Diabetes
Yes No _________________
Thyroid Problems
Yes No _________________
Other _____________________________________________
Muscles and Nervous System
Cerebral Palsy
Yes No _________________
Convulsions/Seizures
Yes No _________________
Epilepsy
Yes No _________________
Spina Bifida
Yes No _________________
Other _____________________________________________
Bones
Orthopedic Problems
Yes No _________________
Rickets
Yes No _________________
Scoliosis
Yes No _________________
Other _____________________________________________
Psychological and Emotional
Clinical Depression
Yes No _________________
ADD/ADHD
Yes No _________________
Autism
Yes No _________________
Brain Injury
Yes No _________________
Cognitive Impairment
Yes No _________________
Behavioral Issues
Yes No _________________
Other _____________________________________________
Childhood Disease History
Chicken Pox
Yes No _________________
Measles
Yes No _________________
Mumps
Yes No _________________
Other _____________________________________________
Adolescent Social Issues that can Affect Dental Health
Pierced Lips/Tongue
Yes No _________________
Smoking
Yes No _________________
Alcohol
Yes No _________________
Eating Disorders
Yes No _________________
Substance Abuse
Yes No _________________
Oral Infections
Yes No _________________
Pregnancy
Yes No _________________
Other _____________________________________________
Consent to Treatment
The undersigned hereby authorizes the Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a
thorough diagnosis of my child’s dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication, and therapy that
may be indicated for my child. I understand the use of anesthetic agents embodies a certain risk. I have had the opportunity to ask questions and
understand the benefits/risks of the proposed treatment for my child.
Signature ______________________________ ________________ Date: _____________ Dentist signature _________________
Parent/Guardian
Relationship to Child
Rev 12/08